Kroeger Ashley R, Morrison Jacqueline, Smith Andrew H
Department of Pediatrics, Section of Critical Care Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA.
School of Medicine, Vanderbilt University, Nashville, Tennessee, USA.
Congenit Heart Dis. 2018 Jan;13(1):98-104. doi: 10.1111/chd.12525. Epub 2017 Aug 1.
Unplanned readmission to the pediatric cardiac intensive care unit (CICU) is associated with significant morbidity and mortality. The Pediatric Early Warning Score (PEWS) predicts ward patients at risk for decompensation but has not been previously reported to identify at-risk patients with cardiac disease prior to ward transfer. This study aimed to determine whether PEWS prior to transfer may serve as a predictor of unplanned readmission to the CICU.
All patients discharged from a tertiary children's hospital CICU from September 2012 through August 2015 were included for analysis. PEWS assessment was performed following transfer to the cardiac ward, and starting in January 2014, PEWS scores were also assigned by bedside CICU nurse prior to transfer from the CICU. Scores exceeding a predetermined threshold prompted further stability assessment by provider team prior to transfer.
Among 1320 discharges of 1082 patients during the study period, there were 130 unplanned readmissions during their hospitalization. Following implementation of pretransfer PEWS scoring, there was no significant reduction in unplanned readmission frequency (10.2% vs 9.2%, P = .39). A secondary analysis of PEWS scores revealed cardiac scoring as a strong discriminator of those likely to experience an unplanned readmission, independent of other significant clinical predictors of readmission (OR 1.78, 95% CI 1.17-2.71, P = .007). The resultant multivariate model was a good predictor of unplanned readmission (AUC 0.77, 95% CI 0.71-0.83, P < .001).
While implementation of a pretransfer PEWS assessment did not reduce the frequency of unplanned readmissions in this small single-center cohort, a multivariate model including pretransfer elements of an early warning scoring system, along with other patient characteristics serves as a good discriminator of patients likely to experience an unplanned readmission following CICU discharge. Further prospective investigation is needed to define objective measures of pretransfer discharge readiness to potentially reduce the likelihood of unplanned readmissions.
小儿心脏重症监护病房（CICU）的非计划再入院与显著的发病率和死亡率相关。儿科早期预警评分（PEWS）可预测病房中失代偿风险患者，但此前尚未报道其能识别病房转科前患有心脏病的高危患者。本研究旨在确定转科前的PEWS是否可作为CICU非计划再入院的预测指标。
纳入2012年9月至2015年8月从一家三级儿童医院CICU出院的所有患者进行分析。转至心脏病房后进行PEWS评估，从2014年1月起，CICU床边护士在患者从CICU转出前也会进行PEWS评分。超过预定阈值的评分会促使医疗团队在转科前进行进一步的稳定性评估。
在研究期间1082例患者的1320次出院中，有130例在住院期间非计划再入院。实施转科前PEWS评分后，非计划再入院频率无显著降低（10.2%对9.2%，P = 0.39）。对PEWS评分的二次分析显示，心脏评分是可能发生非计划再入院患者的有力判别指标，独立于再入院的其他重要临床预测因素（OR 1.78，95%CI 1.17 - 2.71，P = 0.007）。所得多变量模型是未计划再入院的良好预测指标（AUC 0.77，95%CI 0.71 - 0.83，P < 0.001）。
虽然在这个小的单中心队列中实施转科前PEWS评估并未降低非计划再入院频率，但包括早期预警评分系统转科前要素以及其他患者特征的多变量模型可很好地判别CICU出院后可能发生非计划再入院的患者。需要进一步的前瞻性研究来确定转科前出院准备情况的客观指标，以潜在降低非计划再入院的可能性。
